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LECTURES 



ON 



LITHOTOMY. 



Vf 



# 



LECTURES 



LITHOTOMY, 



DELIVERED AT 



THE NEW-YORK HOSPITAL, 



DECEMBER, 1837. 



o> vy 



AS 



BPB^HBlSi 












i 



SURGEON OF THE NEW-YORK HOSPITAL, AND EMERITUS 
PROFESSOR OF CLINICAL SURGERY. 



I 



NEW-YORK: 



"*f 



ADLARD & SAUNDERS, 46 BROADWAY 



1838. 






Entered according to the Act of Congress, in the year 1838, by 

Alexander H. Stevens, 

In the Clerk's Office of the District Court of the United States, for the 

Southern District of New- York. 



"5 6-jrz^ 



G. P. Hopkins & Son, Printers, 98 Nassau-street. 




'"saws*- #' ' t£ *■■■ 



LECTURE I. 

On Lithotomy. 

The human bladder, protected in front by the bones 
of the pubes, has been opened in every other ima- 
ginable direction for the extraction of calculi from 
its cavity : superiorly in the median line above the 
pubes in the high operation ; posteriorly through 
the rectum with and without division of the anus, 
or before the rectum in the median line, either 
behind or through the prostate ; inferiorly through 
the perinseum by the side of the prostate, without 
dividing either that gland or the urethra ; and lastly 
through the urethra and prostate. Entertaining, 
in common with the great majority of surgeons who 
have lived since the time of Cheselden, the con- 
viction that the best modes of lithotomy involve a 
division of the urethra and prostate, I shall confine 
my observations to these alone ; for such is the 
extent of this subject, that a description, however 
brief, of the various plans for cutting, distending, 
and tearing the bladder, would occupy the time 
allotted to many lectures. 

Or the Lateral Operation. 

The lateral, or, as it is called by the French, 

1 



4 



the lateralized operation is now almost exclusively 
practised. The essential part of this operation is, 
that upon a grooved staff, previously introduced into 
the bladder and held firmly, the urethra is laid open 
anteriorly to the prostate gland, which is next divided 
in a direction downwards and towards the left side. 
This most important section .is made with a knife 
having a sharp point and convex edge, according to 
the last mode of Cheselden ; with a long knife con- 
cealed in a sheath, and so introduced, then opened 
so as to cut as it is withdrawn, in the operation of 
Frere Come ; with a long straight or curved bistoury, 
having a beak to slide along the groove of the staff, 
according to the plan of Blizard and Sir A. Cooper ; 
and lastly, with instruments which make an opening 
through the prostate and neck of the bladder, either 
by cutting or stretching, or tearing ; or by a com- 
bination of these results, after the method of Hawk- 
ins, Cline, and others ; the whole being done during 
the entrance of the instrument and not, as in the 
former method, during the withdrawal of it. 

Statistical Results of the Operation. 

Pouteau has estimated the fatal results of ope- 
rations for stone at 1 in 40. Bichat at 1 in 6, 8, 
and 9. Cheselden at 1 in 10J, Douglass, Chesel- 
den, and Middleton, at 1 in 6 in the high opera- 



tion combined with incision in perinseo. Mr. 
Civiale estimates the mortality as nearly 1 in 
4 ; Sir A. Cooper at 1 in 7 or 8 ; and this last is 
probably a just estimate ; some of the other state- 
ments are evidently wanting in accuracy, or are 
derived from limited observation. " I have col- 
lected," says Dupuytren " during ten years, as well 
in the public as in the private practice of the most 
distinguished men of Paris and its environs, all 
the cases of operation for stone that have come 
to my knowledge ; and have collated all these 
cases, observed in individuals differing in age, 
sex, and in temperament, operated on by various 
methods ; in seasons, in places, and in conditions 
so often opposite ; and I am convinced that between 
a fifth and a sixth perish in the mass of these who 
are operated on for stone."* 

* A TABLE, prepared by Dupuytren, showing the result of 356 Operations for 
Stone, practised in Paris, or within its environs, in the space of ten years. 



Approximate proportion be- 
tween the number of deaths 
and Cures. 



SEX. 



No. 
of ope- 
rations. 



Periods 
of Life. 



Death. 



Cures. 



Male. 



97 

59 
45 
74 
37 



fr. 3 to 15 
years. 
15 "30 
30 « 50 
50 "70 
70 "90 



10 
18 
11 



51 
35 
56 

26 



1 in 11 



1 in 
1 b. 
1 in 
1 b. 



7 
45 

4 
34 



9 in 100 

13i » « 

22 « " 
24 « " 
29£ " " 



Female. 



7 


3 to 15 





7 


in 





m 100 


1 


15 « 50 


1 


10 


1 in 


11 


9 " " 


7 


50 " 70 


2 


15 


1 b. 


8& 9 


12 " " 


9 


70 " 90 


2 


7 


1 b. 


3& 4 


22 " " 



Total. 



356 | 3 to 90 | 61 | 295 [1 in 6 17 in 100 



Male. 



312 | 3 to 90 



56 



256 



1 b. 5 & 6 



18 in 100 



Female. 



44 [ 3 to 90 | 5 39 | ling 



11* in iui» 



6 

Individual operators have published results far 
more successful than those here given. Thus Mr. 
Martineau of Norwich, England, has published a 
table, showing eighty-four successful operations to 
two deaths. It is to be observed that a large pro- 
portion of his patients were boys, and some of them 
females, and that he encountered but two large 
stones. One of these cases proved fatal. Mr. 
Martineau operates with the knife after the man- 
ner of Cheselden. 

My friend Dr. Dudley states that of one hundred 
and fifty-three operations he has performed, only 
four have proved unsuccessful. This result places 
him first in the list of successful lithotomists. He 
uses the gorget of Cline — a flat, single winged in- 
strument cutting on one side — and he never en- 
larges the opening by a second incision. It will be 
remembered that neither Mr. Martineau nor Dr. 
Dudley practised in crowded cities. No one can 
read the reports and dissections of the fatal cases in 
London and Paris, without being convinced that 
some of the mortality is owing to causes foreign 
to the mode in which the operation is performed. 
Candour obliges me to make this concession; 
justice to you, among whom are so many who 
have visited or will visit the hospitals of the great 
capitals of Europe, obliges me to add, that this 



operation is often done too much with a view to 
effect, with a rapidity unnecessarily hazardous, 
and upon patients either not duly prepared before 
the operation, or cared for suitably after it. Still 
I consider the lateral operation as essentially de- 
fective and unnecessarily hazardous. 

Of the Causes of Death after the Opera 

tion. 

"About three-fifths," saysDupuytren, "die of in- 
flammation ; the most frequent seat of which is the 
bladder, the cellular tissue of the pelvis, the rec- 
tum, the peritonaeum, the kidneys, the lungs, the 
pleura, or the liver." 

" About one fourth die of hemorrhage, or the 
means used to arrest it; of the rest some perish 
from accidental or concomitant diseases : as ver- 
minous affections, measles, convulsions, small-pox, 
disorders of the digestive system, rheumatism, 
catarrhs, &c." 

Without sufficient personal experience to offer 
an opinion on the these most interesting and im- 
portant statistical statements, I would yet remark 
that too little stress appears to me to be laid upon 
those complications of affections of the kidneys, 



8 



which are found upon dissection to co-exist with 
stone in the bladder, and render operations im- 
proper and fatal ; and secondly, that no mention is 
made of those nervous symptoms, the sinking and 
prostration, from which it is not unusual for patients 
to perish ; and finally, nothing is said of phlebitis, 
or of diffuse inflammation, depending either upon 
infection, or a disordered state of the constitu- 
tion. 

In post mortem examinations we find, according 
to Dupuytren, the neck of the bladder, and the left 
half of the prostate gland, freely and smoothly 
divided by the cutting instrument as far as the cel- 
lular tissue which surrounds the bas fond, and the 
lateral portions of the bladder ; and we see inflam- 
mation of this tissue spreading to all the soft parts 
within the pelvis, the rectum, and the peritonaeum. 
In other cases the neck of the bladder and the left 
half of the prostate are found scarcely divided by 
the incision, but exhibiting a wound of which the lips 
are contused, torn, stretched, and the surface soft 
and gangrenous. In this case, also, the inflamma- 
tion extends into the pelvis, to the rectum, and 
to the peritonaeum ; but from different causes. 

The bladder itself may become inflamed by being 
pinched, stretched, bruised, or lacerated with the 



forceps. This instrument, passed between the blad- 
der and rectum, may seize the stone between the 
coats of the bladder ; or the posterior wall alone of 
the bladder may be embraced by the instrument. 

The cellular tissue of the rectum may become in- 
flamed from the violence done to it ; or its mucous 
membrane may be inflamed by the contact of urine 
arising from an opening through the gut. 

Inflammation of the kidneys, may be transmitted 
from the bladder along the ureters 5 it may occur 
without continuity of inflammation, or in conse- 
quence of calculi in them, or of other pre-existing 
organic diseases. 

Like all other great operations, lithotomy may 
be followed by fatal phlebitis, inflammation of dis- 
tant organs previously diseased or otherwise.* 

Objections to the Lateral Operation. 

Some of the objections to the lateral operation 
are common to all, and some are peculiar to each 
of the several modes in which it is performed ; 
some are derived from the accidents which occur 

■ 

* See an able paper on Phlebitis by Dr. Jno. Watson, in the American 
Journal of Medical Sciences, for November, 1837. 



10 



after this method ; some from reasoning founded 
upon anatomical and pathological examinations 
of the parts interested. 

The opening made in the lateral operation of 
lithotomy is not so situated as to afford the easiest 
and most direct exit to stones, and renders impos- 
sible the extraction of those of unusual magnitude. 
It is too near the lower border of the symphi- 
sis pubis, and too near the descending ramus of 
the left os pubis. Setting aside the insufficiency 
of the opening through the prostate itself; that 
body, and the neck of the bladder, in the efforts 
of withdrawing a stone must be pressed down- 
wards, and over to the right side. The effect 
of this is first to tear the fascia, which unites the 
anterior surface of the neck of the bladder to the 
posterior surface of the pubes; and afterwards, 
when the parts return to their natural situation, 
the track of the wound not being direct, the exit 
of urine may be prevented, and infiltration ensue. 

If to make the incision large, the operator com- 
mences it very far forward, he will divide the 
artery of the bulb, otherwise called the deep trans- 
verse perinaeal. If fearing to wound the rectum, 
he cuts it too horizontally, he will divide the 
deep seated transverse perinatal near its origin. 



11 



If, on the other hand, he carries it more back- 
ward, he approaches and may wound the rectum ; 
and cutting in any direction beyond the limits of 
the prostate gland, he divides the deep perinseal 
fascia, and incurs the danger of urinary infiltration. 

Large incisions cause inflammation ; because 
by extending beyond the limits of the pros- 
tate and the neck of the bladder, they allow the 
urine to come in contact with the cellular tissue of 
the pelvis ; either below or above the pelvic fascia, 
or third fascia of the perinseum, and in contact with 
the peritonaeum. Either inflammation destroys, 
by spreading extensively and rapidly, or, as in the 
case of matter forming under a fascia, by causing 
a gradually enlarging abscess. 

" Small incisions, on the contrary, cause inflam- 
mation by the difficulties they present to the in- 
troduction of instruments, and to the extraction of 
the stone, by reason of which, the track of the 
wound is torn, stretched, and contused."* The 
track of the wound is so often stretched, bruised* 
and torn, without producing fatal effects, or ap- 
parently any bad consequences of moment, that 
these results are, in part, susceptible of a different 
explanation: the lateral and backward displace- 

* DUpuytren, Memoire sur une Nouvelle Maniere, &cv 



12 



ment of the prostate, causing a stretching, or tearing 
of the cellular tissue between the bladder and pubes ; 
a very natural, and to some extent, a necessary re- 
sult of the lateral operation in which the incision is 
made on one side of the gland exclusively, and near 
the symphisis and descending ramus of the pubes; 
or it may arise from the unskilfulness of the opera- 
tor in passing the forceps not into the bladder, 
but one or both blades behind that viscus, and 
tearing the cellular tissue which connects it with 
the rectum. The free passage of urine over the 
surface of a wound does not materially impede its 
healing ; but where it is injected into the cellular 
tissue, as we see in urinary infiltrations, it is one 
of the most irritating fluids in the animal economy. 

In considering the lateral operation, the first 
thing to be attended to is, then, the volume of the 
stone ; success or failure depends upon it. " If the 
foreign body never exceeded three inches in its smal- 
ler circumference, so that the incision in the pros- 
tate might be limited to three quarters of an inch, 
or a few lines more ; the operation when well per- 
formed, would seldom or never be followed by 
fatal consequences. When it measures four inches 
and a half in its lesser circumference, or when 
the sum of its two lesser diameters amounts to 
three inches, the patient may recover, but the 



13 



chances are very much against him ; and when it 
exceeds this volume, death is almost sure to be 
the result of the operation. 

The surgeon is in this dilemma : he must either 
use force, or make a long incision ; the former 
lacerates the prostate and cellular tissue, bruises 
the bladder, and stretches its membranes, and 
shocks the nervous system ; the latter prepares the 
way for infiltration of urine : both are fatal nearly 
to the same degree."* 

That these dangers may most generally be avoided, 
by adapting the length and direction of the incis- 
ions to the particular conformation of the perinseum, 
as regards the degree of divergence of the bones 
forming the lower strait of the pelvis, the depth 
of the perinseum, the condition of the L rectum, and 
the magnitude of the prostate gland, and the pre- 
sumed size of the stone, I am ready to admit. 

On the other hand, it is known that the most 
skilful operators have cut parts which should be 
avoided ; and for the want of proper incisions, have 
employed unnecessary violence, and finally have 
sometimes failed in extracting stones not of a mag- 

* See King's Treatise on the stone, page 104. 



14 



nitude to render their safe extraction impracti- 
cable. 

Case I.— -A medical friend, whose statement is 
implicitly to be relied on, informed me that he 
examined, after death, a man operated on with 
Hawkins' gorget, by a surgeon of great celebrity as 
a successful lithotomist, and who had been unable 
to remove the stone on* account of its size. The 
incision was properly made, and the calculus 
proved to be of the size and shape of a hen's egg ; 
and not proportionably so large as one I removed 
from a boy by the bilateral section. 

Case II.— In the first operation I ever performed, 
the calculus was extracted with so much difficulty, 
although the prostate was divided by a second 
incision on the right side, that the patient narrowly 
escaped death from inflammation of the parts 
injured. 

Case III. — A lad about eleven years old, after 
suffering two years, with symptoms of stone in the 
bladder, underwent the lateral operation, which 
was performed in the usual manner with the scal- 
pel, and blunt bistoury. The last incision was 
made in a direction outwards and downwards, 
with one sweep of the knife, and very free ; no 



15 



urine flowed through the womid, until the forceps 
was introduced. The stone which was about the 
size of an almond, was readily extracted, and the 
patient bore the operation well. The loss of blood 
did not exceed two or three ounces. 

Six hours after the operation, the boy being in 
a state of great pain, twenty-five drops of laudanum 
were given to him. Second day, rested pretty 
well during the night ; little, or no urine passed 
through the wound. He complains of a good 
deal of pain, when pressure is made over the 
region of the bladder; warm fomentations were 
applied. At one o'clock, twenty leeches over the 
hypogastric region, and an injection composed of 
senna, I i. sulph. magnes. 1 i. warm water, Oi. — 
At 7, P. M., six ounces of blood were taken from the 
arm. The injection not having operated, another 
with the addition of tincture of aloes was given. 
At 9, P. M., the injection, not yet operating, was re- 
peated ; patient very restless ; abdomen very tender 
to the touch ; no urine through the wound since last 
evening; an attempt was unsuccessfully made to 
pass a bongie through the wound into the bladder ; 
an instrument was finally introduced through the 
penis, and half a pint of urine mixed with purulent 
matter was drawn off. Another injection was 
given, and the bowels were freely evacuated. 



If) 



Pulse now 140 ; respiration short and hurried ; 
skin hot and dry. Have tart. ant. qr.* every two 
hours. Third day, restless all night ; pulse not so 
quick or tense as yesterday; tongue furred; skin 
hot and dry ; abdomen very tender to the touch ; 
passed half a pint of urine this morning. At 3, 
P. M. — Twenty leeches to abdomen, and submu- 
riate of mercury gr. v. internally. — At 8, P. M., 
much worse ; respiration hurried ; pulse rapid ; 
skin hot and dry ; submuriate of mercury, gr. v. 
repeated, and an enema as before. At 3 o'clock 
in the morning, sixty-three hours after the opera- 
tion, the patient expired. No post mortem exam- 
ination was obtained. 

Such occurrences are more common than mere 
reading would lead you to suppose ; for they are not 
like successful operations blazoned forth in the lit- 
erature of the day. But although comparatively safe 
in the case of stones of moderate dimensions, not 
exceeding three inches in their smallest circumfer- 
ence, for those of large size the lateral operation 
offers no resource — cut which way you will, no 
incision or incisions made in this method, can 
give exit, without dangerous laceration and con- 
tusion, to a calculus, whose smallest circumfer- 
ence, when grasped with a forceps, is more than 



17 



six inches in the adult, and proportionally less in 
young patients. 

In this case, the symptoms indicated infiltration 
of urine ; the cut was extensive, and the course of 
the incision not direct. When no urine follows 
the last incision, if the bladder is reached at all, it 
must be by reason of the want of parallelism of the 
external and internal incisions. Here then, was 
just the combination of circumstances calculated 
to produce urinary infiltration — an extensive cut, 
and a tortuous wound. The incision opened the 
pelvic fascia ; the obstruction to the exit of the urine 
by the wound, caused it to be pressed by the con- 
traction of the bladder into the cellular tissue be- 
hind that aponeurosis. Would the infiltration 
have been prevented by passing a catheter into the 
wound after the operation ? Without positive 
facts to settle this question decisively, I would ex- 
press the following as the best opinion I have 
been able to form on these points. If the rectum 
has not been separated from the posterior surface 
of the bladder, by poking the finger or forceps 
there ; or if wounds have not been made at the 
side of the rectum, by rough handling, the intro- 
duction of the catheter into the wound will prevent 
infiltration; otherwise there is danger, even with 
that precaution ; but not certain fatality. It is not 









18 



bruising the track of the wound so much, as mak- 
ing pouches by the side of it, that leads to fatal 
results. A valvular wound, and incisions as ex- 
tensive as can be made, without wounding impor- 
tant parts, are inseparable incidents of the lateral 
operation. 

These considerations, united with the actual 
result of operations for the stone, in all the va- 
rious modifications of the lateral operation, seem 
fully to warrant a trial of a new method, if one 
can be devised. 

Or the Various Modes or Performing the 
Lateral Operation. 

I have had some experience in the lateral 
operation, having performed it fourteen times in 
male subjects ; although, as many of you here 
know, (having been my early pupils, and practising 
near me since I have been in practice,) every one 
has ultimately got well, and entirely so ; yet I 
have always felt that the operation was not so 
perfect as it should be. Under this impression, 
I have tried almost every variety of instrument ; 
the gorget, the scalpel, the beaked bistoury, the 
bistouri cache of Frere Come ; and I have seen 
all these used in this country, and in England and 



19 



France. The advantages and disadvantages of 
the beaked bistoury and the gorget, are set forth 
in most treatises on lithotomy, and in the syste- 
matic works on surgery. In the lateral operation, 
the preference of one or other of these instru- 
ments is more or less a matter of taste, about 
which no one should dispute. But as regards the 
bistouri cache of Frere Come, I consider it a dan- 
gerous instrument ; liable to wound the fundus of 
the bladder, and by no means necessarily making, 
in the withdrawal of it, the definite incision claimed 
as one of its advantages. The incision must be 
larger or smaller, not only according to the gra- 
duation of the instrument, but according as it is 
withdrawn straight, or pushed to one side or the 
other ; or as its handle is elevated or depressed. 
The knife of Langenbeck, and the straight staff of 
Mr. Key, appear to me very awkward instruments : 
after one trial of each of them, I fully^resolved not to 
employ either of them again. The blunt bistoury 
seems to me a very convenient instrument; but 
considering that the incision of the prostate is to be 
made with one sweep of the knife, it must happen 
that this incision is more or less extensive than 
the operator may desire, according as that gland 
is harder or softer, or larger or smaller. The de- 
sideratum is to make an incision of a definite 



3* 



20 

extent ; this object is not precisely attained by the 
bistoury.* 

The following observations of Mr. Stanley ap- 
pear to be a fair statement of the case. 

" An exclusive preference is not to be given to 
the gorget, or to the knife for the incision of the 
prostate. With either instrument, skilfully used, 
the operation may be well done. With a gorget, 

* Professor Dudley gives these opinions : 

" The constant variety in the depth of the perineum in successive patients 
who present themselves for the operation, added to the variable condition of the 
neck of the bladder and prostate gland, including the enlarged, and the indurat- 
ed, or the relaxed and diminished state of this organ, tends very much to expose 
these parts to be unnecessarily and dangerously wounded, when the scalpel 
is selected with a view to open the bladder. A sweep of the knife, the ex- 
tremity of which is made to perform an arc of a circle in the bladder, with a 
force applied sufficient to carry it through a space precisely suited to one pa- 
tient, might with simSar force be quite too extensive for a second, and of in- 
sufficient dimensions in a third." 

" In using the scalpels of the different surgeons, the incision is made after 
entering the bladder, by means of a lateral movement of the hand, arid conse- 
quently more to the hazard of the patient, inasmuch as it is subject to all the 
casualties arising from different degrees of resistance in the parts to be divided 
from their remoteness from the surface, from their size, from the length, and 
breadth of the blade of the scalpel, and from the manner of holding it. Who 
would pretend to accuracy in a piece of dissection carried on in parts, to reach 
which, the instruments are passed through an obscure medium?" 

" Let the prostate gland be enlarged or of its natural size, indurated tfr 
broken down, inflamed or healthy, the incision made by the gorget cannot vary 
in extent or position." — On Calcul&us Diseases. 



21 



properly constructed, there is no risk of wounding 
the internal pudic artery or the rectum, because the 
limits of the incision are determined by the dimen- 
sion and form of the instrument. With a knife, 
in an inexperienced hand, there is not so much 
certainity of confining the incision within its pro- 
per limits. 

" A comparison of the gorget with the knife, so 
far as instituted, is favourable to the former ; but to 
the narrow bladed and beaked knife, first used by 
Mr. Blizard, an advantage belongs, which a gorget, 
from the width of its blade, cannot possess. The 
knife enters the bladder, as Mr. Blizard was ac- 
customed to remark, as easily as a probe. The 
gorget, on the other hand, must meet resistance in 
passing through the prostate ; very much less, how- 
ever, will this resistance be, than it has been usually 
represented, when the gorget has been properly 
made, and it is guided with skill." 

For the young subject, or for a thin adult, the 
knife is especially suited. It is also to be pre- 
ferred for any case in which the bladder is closely 
contracted upon the stone. But for a very fat, or 
for an old subject, in whom, by the enlargement 
of the prostate, or the dilatation of the rectum, the 
bladder is raised much above its natural situation, 
the gorget is better adapted, on account of the 



22 



great distance from the perinseum, at which the 
prostate and neck of the bladder are in such in- 
stance situated. 

Hemorrhage. 

Case IV. — The following case occurred to me 
at the New-York Hospital, in the year 1823. I cut 
a healthy man, 24 years old, with the single cutting 
gorget; the stone was of very moderate size, and 
.was removed very expeditiously ; little blood flowed. 
Three hours after the operation, he became pale, 
and his skin was bathed with sweat, and his blad- 
der distended ; then followed severe straining ; at- 
tended with great pain, and ending in a discharge 
of a globular mass of coagulated blood. These 
symptoms recurred at various intervals, generally 
about once in two or three hours, for four or five 
days; attempts having been made in vain to 
arrest the bleeding by introducing a cylinder of 
lint into the wound ; the bleeding appeared to 
come from the upper end of the wound ; it ceased 
on the 7th day. The left leg afterwards became 
enlarged, as in phlegmasia dolens ; five weeks af- 
ter the operation, three pints of matter were dis- 
charged from an abscess in the leg, and from 
this time he gradually recovered. It was proba- 
bly phlebitis induced by the pressure of the tam- 
pon. 



23 



Urinary Infiltration. 

Case V. — Protot Francois, aged 22 years, of a 
good constitution, and sanguineous temperament, 
had been subject to derangement in the urinary ap- 
paratus for fifteen years, and had frequently passed 
small calculi by the urethra. On the 15th of April, 
1822, he entered the Hotel Dieu, complaining of 
the usual symptoms of stone in the bladder ; he 
suffered excessively in voiding his urine, which 
contained no blood, but a great deal of mucus. A 
spare diet, and baths were ordered. On the 12th, 
the patient was sounded, and the stone recognized. 
On the 1 5th, the operation was performed accord- 
ing to the plan of Frere Come. Incisions were 
first made through the soft parts of the perinseum, 
up to the membranous portion of urethra ; this 
canal was then opened to admit the sheathed knife, 
which was passed into the bladder, opened, and 
withdrawn unsheathed, so as to divide the pros- 
tate to the extent of a little more than an inch. 
The stone which appeared to be very large, was 
extracted with great difficulty ; after several at- 
temps to remove it, which lasted eight or ten 
minutes, its external layers gave way, and were 
crushed ; it was then withdrawn without further vio- 
lence. As several of the fragments escaped from 
the forceps, a few minutes were occupied in clear- 



24 



ing and washing out the bladder. The patient was 
carefully put to bed, and an antispasmodic tisan 
was ordered. He passed the day tolerably well, 
although he seemed much depressed; towards 
evening some uneasiness was felt at the lower 
part of the abdomen; it seemed, however, to be 
occasioned by the passage of gas in the intes- 
tines. On the 17th, there came on vomiting with 
increasing uneasiness in the abdomen. Forty 
leeches were applied to the abdomen, and diluent 
drinks were given plentifully. There was some 
abatement in the symptoms in the night ; but no 
distinct remission. On the 18th, twenty more 
leeches were applied to the abdomen, and twenty 
to the perinaeum. The patient was also placed in 
a bath. On the 19th, the vomiting had disap- 
peared ; but the features were much changed, the 
pulse was wiry, the skin hot and dry, the tongue 
somewhat parched. More leeches, purgatives, 
bath, and fomentations were had recourse to, but 
without effect; the patient died on the 21st. 

Necropsy , the parts in the vicinity of the wound 
were macerated in a brown, purulent fluid. The 
whole of the cellular tissue of the pelvis was infil- 
trated with thick pus ; this infiltration extended into 
the lumbar regions, and filled the iliac fossae. 

The peritonaeum presented to the extent, corres- 



25 



ponding to the suppuration beneath it, abundant 
pseudo-membranous productions, uniting the small 
intestines to one another, and to the bladder. 
The other parts of the body were healthy ; the tis- 
sue of the kidneys seemed, however, to contain a 
little more black blood than usual. 

Sinking in a Bad Constitution. 

Case VI. — The patient was 67 years old, thin 
and feeble. Mr. Lawrence extracted a large cal- 
cuius by the lateral operation ; the patient lost in 
the ten or twelve ounces of blood. Nothing is 
said of any further hemorrhage. " After the patient 
had been removed from the table, two qrs. of crude 
opium were administered, when he soon dropped 
off in a sound sleep. On waking, he complained 
of slight thirst, but said he felt no pain. His pulse 
being feeble, some wine and water was given. His 
pulse continued weak, his muscles tremulous, and 
he could speak only in a whisper ; his tongue was 
always dry, with a brown streak in the middle ; " * 
he died on the third day. Patients of this class 
can only survive an operation by previously im- 
proving their health, and making the operation 
without hemorrhage pain or infiltration. 

* Medical Gazette, Vol. 5, page 160. 



26 



Of the Anatomy of the Parts. 

Before I explain to you the methods of perform- 
ing the Celsian or bilateral operation, I shall of- 
fer a description, with diagrams, of the anatomy 
of the parts concerned in it. 

The surface of the lower strait of the pelvis, 
bounded by two lines which extend from the sym- 
phisis pubis to the tuberosities of the ischia, and 
from these to the point of the coccyx, represents a 
rhombus of which the longest diameter extended 
from the symphisis to the point of the coccyx, cor- 
responds to the rapha. A straight line drawn from 
one tuberosity to the other across the inferior 
strait of the pelvis, divides this space into two 
perfectly equal triangles. In the male, the anus 
is constantly placed at the point where these two 
tines cross each other ; in the female, it is not the 
anus, but the orifice of the vagina which is found 
at this point. The anterior of the two triangles 
into which the perinseum is thus divided, is the 
narrow space within which the lithotomist has to 
confine his incisions. The portion of it selected 
for the celsian operation, is still more limited. 
It may be exactly circumscribed by a crescent 
stretching from one tuber ischii to the other, and 
passing to the level of the bulb of the urethra ; that 



27 



is to say, at nine or ten lines from the anus. Thus 
its transverse length is equal to the distance which 
separates the ischia, its greatest length from before 
backwards upon the median line is nine or ten lines, 
and this regularly decreases as we approach the 
ischia. 

A section of the pelvis made in the median line, 
from the pubes towards the sacrum, and upon an 
adult subject, submitted to congelation, presents 
above the space here described a triangular sur- 
face, the base of which formed by the rapha, is 
nine or ten lines long ; the apex, situated at the 
point where the membranous part of the urethra 
meets the rectum^ is crowned by the prostate^ 
which from this point is elevated upon its inferior 
angle, to pass on to embrace the neck of the blad- 
der. The anterior side of this triangle, formed by 
the urethra, is twelve or thirteen lines long : the 
posterior border, formed by the rectum, is not 
more than eleven or twelve lines in length. These 
two borders, both form salient lines, encroaching 
upon the area of the triangle, which they bound 
in front and rear, and thus contract the space we 
are describing. The salient line which exists upon 
the anterior border, is at first formed by the bulb 
of the urethra; afterwards by the membranous 
portion of this canal which offers a regular and 

4 



28 



constant curvature ; but which, in consequence of 
variations in the volume, or of the projection or 
length of the bulb, is more or less carried back- 
wards, and consequently more or less difficult to 
reach in the operation for stone. The salient 
border which exists posteriorly is formed by the 
anterior and inferior part of the rectum. Accord- 
ing as the rectum is empty or full, contracted or 
relaxed, it advances more or less upon the sides 
of the prostate and towards the membranous part 
of the urethra, and thus it becomes more or less 
liable to be wounded in the operation. 

Immediately beneath the skin of the perinseum, 
we find, 

1st. The superficial fascia. 

2d. In the middle line, the anterior portion of the 
external sphincter ani, formed by the elliptical fibres 
divided into two layers ; of which the external is 
attached to the superficial fascia, while the other 
dips down at the rapha, and becomes confounded 
with the muscles of the bulb, and is continuous 
with the deeper seated fascia. It results from this 
connexion that the external sphincter cannot con- 
tract without rendering tense the perinseum, and 
drawing back the bulb of the urethra. 



29 



3d. Under the external sphincter is found a mass 
of fat filling up the intervals between the more im- 
portant parts. 

4th. Below this mass we find a fibrous fascia 
which, after surrounding the lower part of the 
rectum, passes between the sphincter and ac- 
celeratores urinse ; adheres to the ischia, and loses 
itself in the superficial fascia of the thigh after in- 
vesting the scrotum and uniting to the dartos. It 
forms the first series of membranes placed at the 
inferior strait of the pelvis, destined to support the 
viscera, aid the action of the muscles, and give 
consistence to the parts. To this membrane most 
of the fibres of the external sphincter are attached. 
This muscle cannot contract unless the fascia is 
kept tense and drawn back. 

5th. Beneath this membrane we find more fatty 
matter ; some branches of vessels running from 
without inwards, and from behind forward. 

6th. Beneath this cellular tissue we come to a 
second fibrous membrane, which envelopes the 
root of the corpora cavernosa, the erector penis, 
the accelerator uringe, the bulb and the canal of 
the urethra, and forms a sheath to the vessels 
on the side of the penis. As this fascia, like the 



30 



preceding is inserted into the edge of the ischia, 
they may be considered as two layers of one 
membrane, which as it leaves the bones divides 
itself into layers to surround the parts we have 
described. 

7th. In the medna line, the acceleratores urinse, 
united and confounded together posteriorly, em- 
brace the inferior and lateral surface of the bulb 
and spungy part of the urethra. The posterior 
part of these muscles is united to the sphincter 
and transversales perinsei to form with them a 
very strong fibrous and muscular centre, situated 
at the part of the urethra, which it is necessary 
to cut upon in the operation of lithotomy. Their 
anterior part separates and covers on each side 
a muscular and membranous plane which ex- 
tends outwards and terminates on the corpora 
cavernosa. 

8th. At the sides, the erectores penis extend 
from the internal surface of the tuberosities of 
the ischia to the middle of the corpora cavernosa, 
which they envelope as the acceleratores urinae 
do the urethra. The distance between the origins 
of these muscles is about two inches across the 
perinseum. 



31 



9th. Somewhat more deeply, the transversales 
muscles are seen situated at the posterior part of the 
perinseum, between the erectores penis and the ac- 
celeratores urinse, and at the base of the triangular 
space between these muscles. The transversales 
muscles are divided in the lateral operation, and 
also by a straight transverse incision ; but incisions 
which commence opposite the membranous part 
of the urethra and extend outwards and backwards 
leave them untouched. 

10th. The union of the acceleratores and trans- 
versales is opposite the commencement of the 
membranous part of the uretha, which can only be 
reached by dividing deeply and largely this hard 
consistent mass. 

11th. In the muscular plane of the perinseum we 
find the superficial arteries arising from the internal 
pudic opposite the tuberosities of the ischia, as- 
cending in a direction forward, upward and inward 
along the ascending ramus of the ischia, and grad- 
ually approaching the median line to go to the 
dartos, and inferior part of the body of the penis. 

12th. More deeply seated beyond the middle 
aponeurosis and the acceleratores urinse, we find 
the deep seated transverse artery, or the artery of 



>2 



the bulb ; this arises from the internal pudic some- 
times with the common trunk of the last described 
artery ; it is usually given off at the junction of 
the ischium and pubis whence it runs forward, up- 
ward and inward, gradually increasing its distance 
from the pubes and approaching the bulb. It is 
always situated from an inch and an eighth to an 
inch and a half from the anus ; it reaches the 
bulb rather less than an inch from its posterior 
extremity, and anastomoses in its substance with 
the vessel of the opposite side, or without anasto- 
mosing it divides into branches going to the bulb, 
and to the spungy portion of the urethra. 

13th. More outwardly are seen the internal pudic 
arteries, which coming off from the internal iliac, 
leave the pelvis through the isciatic notch, whence 
they run up close to the internal side of the ischium 
in the direction of the ascending branch of this 
bone, and the descending branch of the os pubis 
until they approach the symphisis and furnish the 
arteries of the corpora cavernosa and dorsum 
penis. The distance between the trunks of these 
vessels at the posterior part is two inches ; in front 
it becomes gradually less. 

14th. Some branches of hemorrhoidal vessels 
are seen at the sides and base of the triangle 



33 



which we have described ; but these will not be 
divided by an incision made an inch in front of 
the anus in the centre and not passing beyond it 
posteriorly and laterally. 

15th. The skin, cellular tissue, membrane and 
muscles, especially the acceleratores urine, being 
removed, we see the bulb of the urethra forming a 
slight projection, never more than a few lines in 
extent. It is liable to be cut during the operation, 
unless the incision is made very near the anus. But 
dividing the bulb at this point is of little moment ; 
its vessel being small, arising from the transversa- 
les perinsei. These last vessels and their larger 
anterior are not liable to be injured, unless the 
incisions are made too near the scrotum, and too 
far from the anus. 

16th. Beyond the bulb we find fatty matter filling 
the space comprised between the bulb and the 
membranous portion of the urethra. This tissue 
contains several small branches of the inferior 
hemorrhoidal arteries, coming from the internal 
pudic. 

17th. Above the bulb in the median line we find 
the membranous portion of the urethra embraced 
and capped on its nearest extremity by the bulb, 



34 



and received at the other extremity into the point 
of the prostate : its length varies from four and 
five to eight and even nine lines. Its diameter 
scarcely exceeds a line and a half or two lines, 
when the urethra is empty ; its parieties are scarcely 
half a line in thickness. It reposes inferiorly 
upon the rectum, from which it is only separated 
by a thin layer of cellular tissue ; it is covered by 
an expansion of the transverse perinseal muscles, 
and is composed of an internal or mucous mem- 
brane, and an external coat of a fibrous and elastic 
nature. According to almost all the modes of 
operating below the pubes, this is the part selected 
for penetrating into the neck and body of the 
bladder, avoiding on the one hand the bulb, and 
on the other the rectum. The extensibility of this 
part of the urethra, permits it to be instantaneously 
expended by the staff, from one line to three or 
four lines in diameter. By the aid of some efforts 
and the successive introduction of sounds of in- 
creasing size, it may be increased to five lines ; 
but beyond this, the narities of the canal, too 
much distended, give way, and allow the urine to 
become extravasated. 

18th. The prostate placed at the summit of the 
space just described, is flat from before backwards 
and of a triangular figure ; its base directed up- 



35 



wards and backwards, is a little grooved towards 
its middle, receiving and embracing the neck of 
the bladder; its summit directed downwards, is in 
relation with the membraneous portion. Upon its 
sides is cellular tissue enclosing veins and arteries 
of moderate size ; upon its anterior surface we 
find cellular tissue and the pudic vessels diminished 
as they approach each other under the symphisis 
pubis. Its posterior surface rests upon the rectum 
to which it is intimately united. Its breadth at the 
base, measured from side to side, is from twenty 
to twenty-four lines, and decreases gradually to- 
wards its summit. Its thickness, a little greater 
at the sides than on the median line, is from ten 
to twelve lines. The portion of the urethra within 
the cavity of the prostate, receives in its posterior 
surface the caput galinaginis, the seminal ducts, and 
those of the prostate. The right and left sides of 
the prostate, form two symmetrical lobes, each of 
which is ten or twelve lines broad ; measured from 
the urethra towards the pubes anteriorly, it is only 
three or four lines in thickness; posteriorly, or 
from the urethra towards the rectum, it is seven or 
eight lines. An incision of the anterior part of 
the prostatic portion of the urethra would almost 
immediately divide the venous plexus, the extremi- 
ties of the pudic arteries and the cellular tissue 
behind the pubes. An incision of the posterior 

5 



36 



part of the prostate would divide one of the semi- 
nal ducts, and soon reach the rectum. Lastly, a 
transverse incision of the right or left lobe of 
ten or twelve lines in extent, would divide the 
cellular tissue of the pelvis : it therefore follows, 
that incisions of greater extent than this cannot be 
made within the limits of this organ, except in a 
transverse direction on both sides at the same 
time. This bilateral division gives an opening of 
from twenty to twenty-four lines in extent, without 
going beyond the limits of the prostate or dividing 
parts which should not be cut. 

19th. The neck of the bladder is the opening by 
which the urinary calculi are reached in almost all 
modes of operating for the stone below the pubes. 

20th. Superiorly next the pelvis and peritonaeum 
the perinseum is strengthened by fibrous and mus- 
cular strata analogous to those of the external sur- 
face of this region below the integuments, In 
fact, beyond the above described parts, are the 
superior aponeurosis and the levator ani muscles. 
The two laminae of the superior aponeurosis 
arising from the edge of the pelvis pass conjointly 
with the levator ani ; which they enclose from above 
downwards, and from without inwards towards the 
median line. They embrace the rectum, the neck 



37 



of the bladder and prostate, and separate the pelvic 
from the perinseal portions of these organs. In 
front, the two laminae of this aponeurosis ap- 
proach each other, and passing from the pelvis 
backwards form the anterior ligament of the blad- 
der, Posteriorly where they are strongest, they 
are intimately united to the rectum and coccyx. 

We thus see that the perinaeum contains three 
distinct aponeurotic chambers ; the highest lies 
between the peritonaeum and the superior aponeu* 
rosis, and is a receptacle for extensive and deep seat- 
ed abscesses next to the peritonaeum. The second 
cavity situated between the superior and middle 
aponeurosis forms like the preceding, a receptacle 
for the products of inflammation which sometimes 
pass on the sides of the rectum towards the margin 
of the anus, and sometimes finding the resistance 
of the inferior aponeurosis too great, extend to the 
cellular tissue of the scrotum, and even to the in- 
guinal region, forming large abscesses. The third 
plane is superficial and rests upon the integuments 
inferiorly. 

Advantages or the Bilateral Operation. 

In the region between the anus and the bulb, the 
bladder may be reached with great facility, by an in- 



38 



cision extending on both sides of the median line 
either straight or curved so as to be concentric with 
the anus. This route to the neck of the bladder is 
direct, and shorter than any other ; it gives an in- 
cision almost absolutely free from hemorrhage, and 
of greater extent with safety ; for the prostate is cut 
upon both sides, thus rendering less necessary any 
laceration of this gland, or any extension of the in- 
cisions beyond its proper limits. It is less liable 
than any other to urinary infiltration ; first, because 
it is direct; secondly, because it does not trans- 
cend the limits of the prostate. It is less liable 
to injury of the rectum, because the incisions 
are carried more nearly parallel to that viscus. 
Finally, for the preceding reasons, and because 
it requires less violence in the extraction of the 
stone, it is less liable to be followed by inflamma- 
tion. 

The opening made in this operation being op- 
posite the largest diameter of the inferior strait of 
the pelvis, and the route to the bladder, as above 
stated, being the shortest and most direct, it fol- 
lows that larger stones may be extracted through 
it, than by any other method, with equal safety 
and without crushing them. The operation is 
more easily performed; the incisions are made 
with more facility ; and there is a certainty almost 



39 



perfect of cutting those parts which should be cut, 
and those alone. The introduction of the forceps 
and the final manipulations for examining with the 
finger the size and situation of the stone, are as 
easy as the structure of the parts will allow, and 
more easy than in the lateralized or any other oper- 
ation. Thus the bruising of the parts, and especi- 
ally the laceration of the cellular tissue, between 
the bladder and rectum, by the slipping of the 
gorget, or the introduction of the forceps, are 
either avoided or rendered as inconsiderable as the 
nature of the case will admit, 

The Celsian Operation. 

The bilateral operation has been performed in at 
least three, if not four, different modes. These I 
shall successively speak of, and offer some reflec- 
tions on each. 

The Celsian method, (though probably Celsus 
never performed this or any other operation, being 
only a compiler,) or as it has been termed in 
modern times, cutting upon the gripe, is even at 
this day, the method practised in modern Greece, 
as I am credibly informed by a native of that 
country. Singularly enough, the description of 
the operation given by Celsus, although scarcely 



40 

admitting a double interpretation, has beeen mis- 
understood and misapplied by some of the earlier 
modern surgeons.* 

* The following passages are extracted fromCelsus. In the first paragraph 
the portion in Italics settles conclusively the much mooted point as to the mean- 
ing of the term coxas in the last passage here quoted. 

Mode of Securing the Patient for the Operation. 

Homo prsevalens et peritus in sedili alto considit, supinumque eura et 
aversum, super genua sua coxis ejus collocatis, comprehendit ; reductisque ejus 
cruribris, ipsum quoque jubet, manibus ad«suos poplites datis, eos, quam 
maxime possit, attrahere ; simulque ipse sic eos continet. 

Mode of Seeking for the Stone in the Bladder. 

Medicus deinde, diligenter unguibus circumcisis, atque sinistra manu, duos 
ejus, digitos, indicem et medium, leniter prius unum, deinde alterum ir 
anum ejus demittit ; dextrgeque digitos super imum abdomen leniter imponit ; 
ne, si utrinque digiti circa calculum vehementer concurrerint, vesicam laedant. 
Neque vero festinanter in hac re, ut in plerisque, agendum est; sed ita, ut 
quam maxime id tuto fiat : nam lsesa vesica nervorum distentiones cum peri- 
culo mortis excitat. Ac primum circa cervicem qujeritur calculus ; ubi re- 
pertus, minore negotio expel litur. 

Mode of Securing the Stone. 

Ergo ultra calculum dextra semper manus ejus opponitur ; sinistra? digiti 
deorsum eum compellunt, donee ad cervicem perveniter. In quam si oblon- 
gus est, sic compellendus est, ut pronus exeat; si planus, sic, ut transversus 
sit; si quadratus, ut duobus angulis sedeat; si altera parte plenior, sic, ut 
prius ea, qua tenuior sit, evadet. In rotundo nihil interesse, ex ipsa figura 
patet; nisi, si laevior altera parte est, ut ea antecedat. 

Mode of Making the Cut. 

Cum jam eo venil incidi super vesicae cervicem juxta anum Cutis plaga 
lunata usque ad cervicem vesicae debet, cornibus ad coxas s^pectantibus pau- 
lum; deinde ea parte qua resima plaga est, etiamnum sub cute altera trans- 
versa plaga facienda est, qua cervix aperiatur ; donee urinse iter pateat, sic ut 
plaga paulo major, quam calculus sit. 



41 



In the second volume of Bromfield's Surgery, 
page 366, we meet with the following passage. 
" Heister, in his books of surgery, has given a 
plate, in order to explain the method of perform- 
ing the operation of lithotomy, as described by 
Celsus. I own I was not a little surprised when I 
examined it, as it was so extremely different from 
the idea I had formed of his intentions : I there- 
fore immediately had recourse to Celsus' works, 
and found the delineation in Heister's surgery, so 
very foreign to Celsus' account, that I was induced 
to perform the operation on a dead subject, ac- 
cording to the directions given by him, as I under- 
stood them." 

The annexed plate is copied from Bromfield.* 
It will be found to correspond perfectly with the 
language of Celsus, — the proper interpretation of 
which undoubtedly is, that a curved incision is made 
in front of the anus upon the stone pressed towards 
the wounded portion of the perinaeum. Bromfield 
appears to have been the first who correctly inter- 
preted the text of Celsus. More recently, in 
France, Chaussier, Beclard, M. Ribes, and Dupuy- 
tren, have construed it in the same way. 

Bromfield, in performing the operation upon the 

* See plate 1. 



42 



dead subject after the Celsian method, extracted 
the stone through the prostatic portion of the 
urethra without dividing it. Some weeks after- 
wards the gentleman who examined the parts for 
him, an eminent anatomist, repeated the operation 
on a subject nine years old, and found that the 
wound in the bladder had been made under the 
orifice of the urethra, and being made transversely, 
both ducts of the vesiculse seminales were divided. 
The result of this trial seems to have discouraged 
Bromfield and his friend. Had he employed the 
grooved staff perhaps the result would have been 
different. 

Whether Raw, (who probably cut more persons 
for the stone than any other surgeon that ever 
lived,) made the Celsian incision upon the grooved 
staff or not, is uncertain. The use of the grooved 
staff was common in Raw's time, and is not men- 
tioned by Celsus. Raw kept his method secret 
though he operated publicly. His only answer 
when questioned was, "Read Celsus. Read Cel- 
sus." 

It is hardly necessary to dwell upon the imper- 
fections of this method in adults. The finger is 
scarcely long enough to hook the calculus. It might 
indeed be held by a curved instrument, but the 



43 



pressure of the stone against the neck of the blad- 
der with the degree of force necessary to fix it, 
must certainly be attended with danger. Lastly, 
there is an uncertainty as to the parts which are 
cut. 

The great defect of the Ceisian operation is the 
want of a staff, — its peculiar advantage is that it 
extends on both sides of the median line. The 
rectum deviates so little from the middle line, that 
for all practical purposes the parts may be con- 
sidered symmetrical. By the use of the staff, un- 
known to the ancients, the bilateral incision may 
be horizontal, passing transversely across the peri- 
nseum immediately behind the bulb ; or horizontal 
on one side of the rapha and curved downwards on 
the other ; or lunated, or oblique, passing from the 
right to the left side of the rapha and from before 
backwards ; or sigmoid, with its central part cros- 
sing the rapha.* 

And these incisions may preserve their form 
until the prostate and neck of the bladder are 
divided. I am not aware that any of these incis- 
ions, except the transverse and lunated, have been 
attempted ; but so far as reason and anatomy can 

* See plate. 

6 



44 



decide, any of these methods may be followed 
with almost equal safety. 

If it be objected that the lips of the wound, want- 
ing the support of an undivided portion of prostate, 
will not come in apposition so as to heal kindly, 
my answer is, that in the lateral operation, when 
stones of unusual magnitude have been met with, 
the prostate on the right side has been cut in 
various directions, and no ill consequence has fol- 
lowed; and moreover, in the bilateral operation, 
in which the double incision is made an essential 
part, the healing of the wound is not less rapid 
than where that gland is divided on one side only. 

Dupuytren thus describes his operation : 

"Let the patient be placed and secured in the 
same way as for the lateral operation. 

" Then having with the staff ascertained the pres- 
ence and probable size of the stone, the surgeon 
ought to give it a vertical direction, its shaft 
making a right angle with the axis of the body ; 
and its curvature being rather elevated under the 
concavity of the symphisis than supported at its 
lower and back part on the side of the rectum. 
A skilful assistant ought to maintain it steadily in 



45 



this position. Armed with a double cutting scal- 
pel, the surgeon makes in the perinseum a curved 
incision, transverse, embracing the anus within its 
concavity. The skin, the elastic subcutaneous 
cellular tissue, the superficial perinseal aponeurosis, 
the anterior part of the external sphincter, and the 
posterior part of the bulb of the urethra should be 
successively divided in the same direction, until we 
are able to feel distinctly the catheter and its 
groove. 

"During this part of the operation we should not 
lose sight of the direction of the urethra and its 
relations with the intestine. The instrument should 
carefully avoid the anterior convexity of the in- 
testine, and follow the course of a line that should 
extend from the anus to the anterior surface of the 
bladder and hypogastrium. If these precautions 
are neglected the rectum will be wounded. The 
lower surface of the urethra should be divided with 
the point of a bistouri directed against the groove 
of the catheter to the extent of three or four lines. 
It is important that the point of the bistouri 
should rest in the groove of the staff so as to 
avoid the possibility of denuding or cutting the 
rectum, which in this place is in almost direct con- 
tact with the prostate and urethra. 



46 



The nail of the left index finger kept in the 
wound, should be introduced into the furrow of 
the catheter to serve as a guide to the lithotome, 
the blunt extremity of which, penetrates without 
effort, along the incision already made. It is then 
necessary to direct the convexity of the curve of 
the instrument at its lower part from the side of 
the rectum, so that its concavity, lying upon the 
catheter in the proper direction, it may be more 
easily directed onwards as far as the bladder. 
The immediate contact of the two metallic bodies, 
announces that the lithotome is properly placed ; 
and the surgeon, seizing the staff with the left 
hand, so as to lift it towards the symphisis pubis, 
and to push its beak deeper into the bladder, the 
beak of the lithotome is pushed along the groove 
of the staff. 

" The catheter ought to be withdrawn as soon as 
the discharge of urine between the two instruments 
and the contact of the stone announce that the 
second period of the operation is accomplished. 
The lithotome is afterwards turned over so as to 
present its concavity downwards ; and then after 
employing it as an exploring sound for the purpose 
of again measuring the volume and reconnoitering 
the situation of the calculus, the surgeon opens 
the instrument and gently withdraws it ; gradually 



47 



lowering the handle towards the anus, until its 
blades are entirely disengaged. By this method 
we cut more exactly around the bulging of the rec- 
tum, and prevent the extremities of the cutting 
edges, in spite of their distance outwards, from 
approaching these parts too nearly. 

" It is proper, after the removal of the lithotome, 
to pass the index finger of the left hand into the 
bladder, so as to measure the extent of the incisions, 
to be assured of the state of parts, and to serve as 
a guide to the forceps. The finger ought to rest 
in the posterior part of the wound, and thus render 
impossible that deviation of the forceps, sometimes 
observed, in which it passes not into the bladder, 
but into the cellular tissue between this organ and 
the rectum." 

The double lithotome of Dupuytren ought not to 
be employed by any one who is not thoroughly 
drilled in the use of it. He must handle it as he 
would a double barreled hair trigger pistol,* and 
be prepared to lacerate the urethra while passing 

* " Sir A. Cooper, on one occasion proposed to perform the operation of 
lithotomy, in the presence of a large class, with the bistouri cache, but after 
getting the blade in the bladder he commenced its withdrawal with the cut- 
ting edge turned to the symphisis pubis. As soon as he discovered what was 
done he cautiously withdrew it from the wound, and advised the class never to 
use an instrument of that description.'' — Dudley in Calculous Diseases, p. 19. 



48 



its beak along the groove of the staff. It is liable 
to the same objection as the bistouri cache of 
Frere Come, in that it must expose the fundus of 
the bladder to injury ; and the more especially as 
the urine is always discharged through the dis- 
tended and lacerated urethra before the blades are 
opened. I cannot think it unattended with danger 
to open a cutting instrument even with blunt points 
in a contracted bladder — an unlucky movement of 
the patient might push the bladder against these 
points ; and if not, the internal membrane of the 
bladder must come in contact with the edge of the 
instrument. The curve of the blades I think ob- 
jectionable in a route of no more than the length 
of the prostatic portion of the urethra ; an attempt 
to make the incisions spheroidal is a useless re- 
finement, and the advantage of it is more than lost 
by the jagged incisions which such an instrument 
must necessarily make when not moved with 
mathematical precision, and through parts abso- 
lutely motionless. The more important of these 
objections holds good against the modification of 
Dupuytren's instrument by the ingenious M. Char- 
riere. 

But neither this instrument nor that of Dupuy- 
tren, can be readily opened in a urethra surround- 
ed by a hard prostate. Before the substance of a 



49 



hard postate would yield to the direct pressure of 
the edge of the instrument, the blades would bend. 
Then if the ends of the knives are not passed be- 
yond the prostate and into the bladder, the remote 
portions of the prostate, and the neck of the blad- 
der* are not divided. But Dupuytren, in one of 
the plates accompanying his work, represents the 
lithotome as passed more than an inch within the 
bladder, the blades being open and ready to be 
withdrawn. Now it must be understood, that the 
bladder is empty during this stage of the operation ; 
the urine having passed by the side of the lithoto- 
me as soon as it is introduced : of course it 
must collapse against the edges of the instrument, 
even if it does not spasmodically press itself against 
them. Under such circumstances it would seem 
that its mucous membrane, at least, if not the mus- 
cular and peritoneal coats, is greatly endangered. 

In the next lecture I shall show you a more 
simple and safe method of performing the bilateral 
operation. 

* This term is used in various senses ; I mean by it, that part of the bladder 
alone which corresponds to the prostate. 




A triangular space formed by the anterior portion of the perinseum, 
lying between the symphisis pubis (B,) and anus (D,) and bounded 
laterally by the rami of the pubes and ischia. The point A cor- 
responding to the right tuber ischii, and the point C to the left. 
The distance between these two points being about two inches and 
three quarters on the male pelvis. The line B D, extending from 
the symphisis to the anus, is also about two inches and three 
quarters long. 

ENF. The semilunar incision ofDupuytren, forming the segment of a 
circle, the centre of which is the anus, and the radius of which is 
rather more than an inch, English measurement. 
G H. The transverse incision, the length of which is equal to the cord 
of the preceding arc; that is, about an inch and three quarters. It 
cropes the rapha at right angles at the point O, between ten and 
eleven twelfths of an inch from the anus. 

I OK. The oblique or diagonal incision, one third of which is on the right 
side, and two thirds on the left of the rapha. 

I O M. The sigmoid incision extending on either side of the rapha to the 
same distance as the preceding, but in consequence of its curvature, 
giving a cut of somewhat greater extent. 

G O M. The incision straight on one side and curved on the other. 



51 




N B C. A triangle representing the space formed by the perinseum, the 
urethra and rectum, as seen on the median line, in a subject sub- 
mitted to congelation and divided from the rapha backwards through 
the middle. 

D B. The perinaeum. A C. The course of the urethra. B C. The 
course of the rectum. At the point C, where the prostatic portion 
of the urethra terminates and the membraneous part begins, the 
urethra and rectum are in contact, or nearly so. 

The salient line A D F., represents the bulb of the urethra. 
The salient line B F C. represents the anterior wall of the rectum, 
when it is distended with faeces. This last line is subject to great 
variation, according as the rectum is more or less distended. 



LECTURE II. 

On Lithotomy. 

I venture to offer to the profession a new instru- 
ment for the bilateral section of the prostate ; in 
form it resembles a large olive, with a beak at the 
extremity, with cutting edges at the sides, parallel 
to its longest axis, and with a straight handle. 
The instrument of which there are three sizes, and 
the manner of employing it, will be readily under- 
stood by the annexed engravings. The grooved 
staff employed in connexion with this instrument, 
is as wide as the urethra will admit, and the 
groove gradually terminates as it approaches the 
end of the staff. 

The advantages in the use of this instrument 
are, first, that the circular form of a transverse 
section, gives an opening through the gland of 
three diameters instead of two, as when a flat in- 
strument is employed; — thus it is not necessary 
to carry the incision so far laterally to obtain an 
opening of given dimensions ; and hence there is 
less likelihood of hemorrhage from injuring the 
plexus of vessels that surrounds the prostate. 



54 



Second. The prostate is cut horizontally, and 
though not absolutely, yet for all practical purposes 
in its greatest diameter. 

Third. The rectum is pushed back by the con- 
vexity of the posterior part of the instrument. 

Fourth. As the prostate is stretched transversely 
across the instrument, the section is made by a 
clean cut, and with so little resistance that the in- 
strument does not, like ordinary gorgets, require to 
be thrust in with force, but may be passed lightly 
along until the section is completed. Thus there is 
less danger of wounding the fundus of the bladder 
by a sudden cessation of resistance from the parts 
divided ; they are, in fact, divided without force. 

Fifth. The easy division of the prostate obviates 
the danger of tearing the cellular tissue which 
connects the anterior surface of the bladder to the 
posterior wall of the ossa pubis. 

Mode of Operating. The following is the method 
I have adopted, and the one I would recommend 
for performing the operation. 

Let the patient be secured in the usual manner, 
but with the pelvis rather higher than the trunk, on 



55 



a firm flat table, with only two or three thicknesses 
of blanket under him. The rectum should have 
been previously emptied by a dose of oil given on 
the night preceding the operation, and the urine 
should be retained for a short time previous. The 
patient secured, let the assistant who is to hold 
the staff be placed on the patient's left, and a 
second assistant on his right, to support the rectum 
with a cloth, in case of prolapsus. The staff is 
then to be introduced. If you are quite certain 
of the existence of a stone, I would advise you not 
to delay the operation because you do not feel it 
when the patient is on the table ; and much less 
would I advise you to ask all the assistant surgeons 
to satisfy themselves of the presence of the calculus. 
During these painful and protracted manoeuvres, 
the urine is often discharged, and you lose the 
advantage of its presence in the bladder; Let 
only one of the assistants sound, and in doing so 
press the urethra against the groove of the staff 
to prevent the escape of urine. Exhort your pa- 
tient not to strain ; and while you are encouraging 
him with the hope of speedy relief, mark with 
your eye, but more especially by feeling with your 
finger, the exact situation of the two tuberosities 
of the ischia ; the divergence of these two bones, 
the lower border of the triangular ligament, and 
the bulb of the urethra. The bulb is situated 



56 



directly at the lower border of the ligaments, 
which to pretty firm pressure will impart a greater 
degree of resistance than the parts between it and 
the anus. In a deep pelvis and with an enlarged 
prostate, you may expect to find a deep perinseum, 
and should be prepared to find the bladder more 
than usually out of reach. Plan for yourself an 
incision of a crescentic shape, posterior to the 
bulb, but near it — nearest it when the pouch of 
the rectum, as in old men is much enlarged, and 
in those whose pelvis is naturally narrow ut the 
inferior strait. Let its convex side be next the 
bulb, its horns between the anus and the tuberosi- 
ties of the ischia, not below the centre of the anus, 
for here are the hemorrhoidal vessel ; not within a 
quarter of an inch of the ischia, for by approach- 
ing the bone too closely, the incision might reach 
the internal pudic artery. Now covering the anus 
with three fingers of the left hand, press the rec- 
tum backward and tighten the skin of the perinseum. 
As a general rule, make your incision one inch 
and a quarter anterior to the anus, and in length 
about one inch and three quarters, with slight con- 
vexity forwards. When the incision through the 
skin is completed, pass the fingers of the left hand 
into the wound, so as to tighten the fascia to be 
cut and to press back the rectum. If you fear you 
are approaching too near the bowel, put your 



57 



linger into the rectum, and ascertain the relations 
of the incision to that part. Continue the incisions 
in the same plane, but rather more forward, es- 
pecially if you find your cut very near the rectum, 
for the gut bulges forward as it ascends. Continue 
to press back its anterior walls, — now pass the 
finger deep into the centre of the wound, and turn- 
ing forward its radial edge, feel for the staff and 
for the bulb of the urethra. Holding your finger 
upon the bulb and the nail upon the staff, pass a 
small bistoury beyond it, and cut the membraneous 
part of the urethra upon the groove of the staff. 
This part of the urethra is surrounded by a dense 
fibrous sheath, the knife for dividing it should be 
sharp at the point or very narrow. It is not un- 
common to witness delay in exposing the staff; 
this I believe arises from not having the urethra 
stretched by a large staff, from miscalculating the 
thickness of the fibrous sheath surrounding it, or 
lastly, from using a broad pointed knife. The 
membraneous portion being divided, pass the beak 
of the bisector into the groove, and holding the 
staff with the left hand, glide the bisector with the 
right hand along the groove until the escape of 
urine advises you that the section is completed. 
The angle which the bisector should make with 
the staff, should be just enough to keep the beak 
in the groove. If the patient is young, you may 



# 



58 



be well assured that you can reach the bladder 
with the finger. So you will in adults and old 
persons, unless the pelvis is deep or the prostate 
enlarged. In the latter cases only you may leave 
the staff in the bladder to guide the forceps ; but in 
my own practice, I have always withdrawn the staff 
as soon as the section of the prostate was com- 
pleted, introducing my finger into the wound at the 
same moment. 

The Prostatic Bisector was employed in the two 
following cases. 

Case VII. — John Roselle, eleven years old, 
small of his age, and labouring under symptoms of 
stone in the bladder for nearly five years, was ad- 
mitted into the New-York Hospital, in the early 
part of November, 1836. After an examination 
with the sound and finger in the rectum, Dr. 
Stevens expressed his opinion that the stone was 
of unusual size for a child, and he decided upon 
performing the bilateral section of the perinseum 
and neck of the bladder by which the greatest pos- 
sible space could be procured for the safe removal 
of the stone. Accordingly on the 10th of Novem- 
ber, the necessary preliminaries having been ad- 
justed, and being prepared with an instrument he 
had devised for the operation, and which he terms 



59 



the prostatic bisector, he made a semilunar incis- 
ion through the integuments about midway be- 
tween the anus and the lower border of the sym- 
phisis pubis, the ends of the incision pointing 
backwards. The cellular tissue and the condensed 
fibrous structure forming the union between the 
anterior fibres of the sphincter ani and the poste- 
rior fibres of the acceleratores urinse, dec, were 
next cut in a direction parallel with the first incis- 
ion, and the wound thus carried completely down 
to the membraneous portion of the urethra which 
was then divided. The scalpel was now laid aside, 
and the bisector with its beak properly adjusted in 
the groove of the staff was then pushed on into 
the bladder; cutting through the prostate gland 
still in a direction nearly parallel with the primary 
incision, and dividing it on either side of the 
urethra through its greatest diameter. 

Although the incision thus made into the bladder 
was large, in consequence of the great size of the 
stone it was withdrawn with difficulty ; and in fact, 
before disengaging it from the wound, the operator 
was obliged to divide the transverse perinseal mus- 
cle of the right side, this muscle and its fellow 
being stretched over the upper part of the stone 
The stone was in form a flattened ovoid composed 
of phosphate of lime ; its weight was three ounces ; 

8 



60 



its measurement six and a quarter inches in its 
longitudinal, and four and a half in its shortest 
circumference. It was finally extracted by a curved 
lever and the finger of the operator. 

No untoward symptoms followed the operation 
except that from some improper indulgence in food, 
the child had an attack of erysipelatous inflamma- 
tion around the wound. This, however, was soon 
overcome by anodyne lotions, and a stricter atten- 
tion to regimen ; and before the close of the month 
he was sufficiently well to leave the hospital. A 
slight oozing of urine continued for a few weeks 
longer; but the wound was examined in January 
and found to be entirely healed. 

Case VIII. — Noah Avery, a mulatto child, aged 
six years, was admitted into the New-York Hospi- 
tal, November 14th, 1837. He had an expression 
of suffering in his countenance ; he was often 
fingering and pulling at the prepuce ; the integu- 
ment, and indeed the whole body of the penis, 
were unusually developed. The act of micturition 
was repeated almost hourly, and attended with 
much pain and straining, and generally with sim- 
ultaneous discharges from his bowels. When the 
bladder has partially emptied itself, and the spasm 
is coming on, he arrests the flow of urine by pres- 



61 



sing upon the end of the penis, and after a few 
moment's delay, suffers it to flow. He passes his 
water with most ease when his hips are elevated; 
and his mother is in the habit of raising him by the 
heels and shaking him ; and after this he is easy so 
long as he is kept with his heels elevated. Some- 
times he requires his mother to press upon his ab- 
domen ; this and the shaking by the heels, are often 
repeated ten or twelve times during the course of 
the night; and in the intervals he rests upon his 
knees with the buttocks elevated and the face upon 
the pillow. He is not disposed to run about, but 
walks with a cautious step. Occasionally, he is 
seized while walking, so suddenly and severely 
with pain at the end of the penis, that he falls as if 
struck down. The urine is turbid and leaves a 
tenaceous matter adhering to the vessel. He has 
had these symptoms in a greater or less degree 
since the age of thirteen months. The existence 
of a stone was first ascertained by sounding, about 
a year since. In damp weather, and after expo- 
sure to cold, all these symptoms are aggravated. 
He has long been accustomed to take large doses 
of laudanum. 



He had been exposed to the contagion of meas- 
les prior to his admission, and soon afterwards 
went through an attack of this disease without any 
bad symptoms. 



62 



On the 25th of November, the fever having left 
him, and the urine being charged with free acid, 
he was put on the use of carbonate of soda grs. 
x. three times a day, taking every night his ac- 
customed draught containing tinct. opii. gtt. xxv. 

On the morning of the 2d December, he had an 
injection which procured two free discharges, after 
which he took tinct. opii. gtt. lx., and at noon 
was brought into the theatre to undergo the oper- 
ation. After securing him, the sound was intro- 
duced ; it immediately encountered the stone. The 
cries and straining of the child caused a discharge 
of urine and prolapsus of the anus. The escape 
of urine, which pressure upon the prepuce around 
the staff failed to arrest, was stopped by pressing 
the urethra against the instrument. The bowel 
was then pushed up and kept up with a cloth by 
the operator while making his incisions. After the 
first incision, a large and consistent mass of faeces 
was discharged, and during this discharge the 
operation was suspended. The steps of the oper- 
ation were the same as in the case of John Roselle 
already related, except that the membraneous por- 
tion of the urethra was first penetrated beyond the 
bulb, with a small curved flat-pointed bistoury, with 
its edge toward the groove of the staff, and divi- 
ded in the withdrawal of the instrument with its 



63 



edge downwards. The prostatic bisector em- 
ployed in this case was of the smallest size — a 
thread passing round its bulging part and includ- 
ing the staff at the same time that the beak of the 
one rested in the groove of the other, measured one 
inch and a half. The staff employed was as large 
as the urethra could admit, and deeply grooved. 
Less than half an ounce of blood was lost in the 
operation. The stone was readily extracted with 
the finger and scoop or curved lever. It was as 
large as a pigeon's egg, rough, and of a yellowish 
gray colour. 

After the operation, the patient was taken to a 
warm bed, placed upon his back with his knees 
elevated, and a gumelastic catheter introduced into 
the bladder through the wound, care being taken 
to pass it to the precise distance necessary, and 
no further than the termination of the incision in 
the bladder. At four o'clock P. M., he had had 
several paroxysms of spasm, and bearing-down 
efforts like those before the operation, during and 
subsequent to a discharge of faecal matter from 
his bowels; pulse 135, — skin hot — urine flowing 
through the catheter and at intervals by the natural 
passage. At 9 P. M., — pulse 140 — skin hot and 
moist, occasional spasms, no tumefaction or ten- 
derness of abdomen, very slight tenderness on 



64 



pressure in a direction behind the pubes. V. S, 
I vi. catheter removed ; fomentations to the abdo- 
men, his usual anodyne. 

Second day, at 8 A. M. — Pulse 140, tongue 
white, skin hot and moist, drops of sweat on the 
upper lip, over the face generally and on the 
upper part of the trunk ; urine passing every two 
or three hours through the penis and through the 
wound ; countenance and spirits good ; pain rather 
increased ; he asks his mother to press upon the 
abdomen. Fomentations continued over the ab- 
domen. — Castor oil, i ss., diet of arrow root, drink 
of cream-of-tartar-water and lemonade. At 9 P. 
M., the oil had operated freely ; abdomen soft but 
somewhat tender; eleven leeches were applied 
to the inguinal regions, and the fomentations con- 
tinued. 

Third day, at 9 A. M. — Rested well last night; 
urine flowing both ways ; pulse 130 ; no pain ; 
skin natural; tongue moist at the edges, slightly 
brown in the centre ; he had an operation from 
his bowels before daylight. At 4 P. M., pulse 
120; has asked for oysters; sits up in bed and 
amuses himself with toys ; sleeps indifferently on 
his back or on either side, and with his thighs 
either extended or drawn up. 



65 



Fourth day, at 9 A. M. — Increase of the pa- 
roxysmal pains, tenderness in the inguinal re- 
gions. Fomentations continued, castor oil, 5 ss. 
diet, gruel. At 4 P. M. — the oil had operated, 
all the symptoms aggravated, pulse 140. Under 
a supposition that the symptoms might be owing 
to the presence of a small portion of the calculus 
broken off and left behind, a female sound was 
introduced into the bladder, but nothing was dis- 
covered. 

Fifth day, pulse 120, at 9 A. M., — skin moist, 

— upper lip covered with drops of sweat, — urine 

free both ways, - — slept well in the intervals of his 

paroxysms which recurred every few hours, — 

was ravenous for hearty food during the night, — 

allowed roasted apples, — during the day, he 

amused himself with his toys. 

» 

Sixth day, at 9 A. M., — pulse 120, — no heat 
of skin, — urinates mostly through the penis. He 
took an ounce of castor oil in the afternoon, which 
brought away two large lumbrici, one of them 
nearly a foot long. 

Seventh day, — slept without his opiate last 
night — much improved, — permitted to take ani- 
mal food. 



66 



Ninth day, at 9 A. M., — sits up nearly all the 
time, but still has occasional pains in the abdo- 
men, — took two ounces of the compound infusion 
of senna, which operated repeatedly, and with 
great pain, but brought away another worm. 

Tenth day, — some purging and tenesmus, — 
ordered chalk mixture, I ss., with tinct. opii. gtt. 
xx. 

Eleventh day, — urine passes through the penis 
without pain ; the wound which has always looked 
well, is now contracted to the size of a pea. 

On the 17th of Dec, the wound had healed, 
and on the 22d. of this month, he was discharged, 
cured. 

In looking back upon the details of this case, it 
is important to note how the constitutional irrita- 
tion and severe paroxysms of pain, like those 
caused by the calculus, were excited — first by 
the worms, and afterwards, by the oil and sen- 
na. Had the boy been cautiously indulged in the 
use of food, it would, I think, have been better 
than to have bled and purged him. 



67 



On Preparation and Choice of Season for 
the Operation. 

In this country 1 believe no one season is more 
favourable for operating than another. It was 
formerly the practice of surgeons to prepare their 
patients by bleeding, and a course of dieting. Of 
late years, all preparation is very much neglected ; 
perhaps too much so. If the secretions are sup- 
pressed, they should be restored. The condition 
of the urinary organs may very often be materially 
improved by the use of alkaline or acid remedies, 
according to the indication furnished by the state 
of the urine. The best condition of the system is 
that of good, but not too high health. 

Of Sounding. 

The best instrument for sounding is a straight 
staff, or one with a very slight curve ; this may be 
moved about the bladder with less pain than one 
of the common kind. If the stone is not readily 
found when the bladder is full, it should be emptied, 
and the position of the patient should be varied. 

For estimating the size of the stone, and the 
condition of the prostate, let the patient be placed 
in a half recumbent posture ; place yourself on his 
left, and with the right hand press above the pubes, 

9 



68 



while the index finger of the left hand is passed 
high up the rectum, your middle finger must be 
buried in the cleft of the nates, and the thumb rest- 
ing in the pudendum. The prostate, and probably 
also the stone, will thus be brought within your 
reach. Next let an assistant press against the 
pubes ; and taking the staff in the right hand, move 
it gently around the bladder, and in this way get an 
idea of the size and sensibility of its inner surface. 
Then press the hand backward. The distance of 
its posterior surface from your finger, is the meas- 
ure of the thickness of the prostate gland. When 
you strike the stone, judge of its magnitude by the 
kind of shock it gives the staff. If the stone is 
found with difficulty, and readily lost, you may 
infer that it is small; but if it is readily encoun- 
tered, and if the instrument may be moved without 
ceasing to touch it, you may presume that the 
stone is large. If the sound strikes the stone the 
moment it enters the bladder, and cannot afterwards 
be pushed on or moved about, the stone probably 
fills the bladder. In this case it also ought to be 
very plainly felt by the finger in the rectum. The 
hardness and smoothness of calculi may also be 
ascertained by the sound, If, after repeated ex- 
aminations, the stone is always found in the same 
part of the bladder, it may be supposed to be sac- 
culated or adherent. 



69 



There is much resemblance between the feel of 
a soft or fusible calculus and a hard carcinomatous 
bladder. But in this latter case, the sensation of 
a hard body will always be felt in the same part of 
the bladder ; in the former it will most probably vary, 
I have known the point of the sound to get hitched 
under a projecting band of muscular fibre of the 
bladder, and when suddenly forced from this posi- 
tion, to communicate to the surgeon a very decep- 
tive shock. 

Of Sounding the Patient on the Table. 

The following case is published in the Archives 
Generales, August 1826 : 

Case IX. A child, aged two years and a half, 
had suffered from uneasiness in the penis, and pain 
on making water. On sounding, M. Roux thought 
he felt a stone ; but on the operating table, on 
sounding again, the results were less satisfactory. 
M. Velpeau, and others, introduced the instrument, 
and could not satisfy themselves of the presence 
of a calculus. M. Roux, however, thought he felt 
one ; and the recollection of a former case where 
he alone had discovered a small calculus in the 
bladder, determined him to operate. The opera- 
tion was performed with Hawkins' gorget, but no 
stone could be found. Peritonitis succeeded, and 



70 

in sixty hours the child was dead. No examina- 
tion of the body was permitted. 

This case will probably be considered as show- 
ing the propriety of always sounding the patient 
upon the table just before the operation. 

Mr. Liston holds this language : 

"The operator will, for his own sake, satisfy 
those who are present as well as his advisers and 
assistants of the fact that there is a stone in the 
bladder.* This is the advice usually given ; but 
I cannot give it to you, nor do I follow it. Rather 
satisfy yourself, some days before the operation, 
of the existence of the stone. If you cannot satisfy 
yourself beyond all doubt, seek other counsel ; but 
when you place your patient on the table, let it 
be for the purpose of his undergoing the operation 
and for that solely. This surely is enough for one 
day's endurance, without the torture of such ex- 
aminations as are implied in the passage above 
quoted, and which are practised from a sort of 
courtesy to those who may be present. How often 
does it happen that the urine escapes during the 
repeated sounding ; how often do the efforts it ex- 

* Listens' Elements. 



71 



cites cause prolapsus ani ! Who is to answer 
for the skill and tenderness of those around you ! 
I have seen the sounding done very roughly when 
the staff was yielded to a person who should have 
been only a spectator. It is true that instances 
have occurred in which the operation has been 
performed and no stone existed. But this does 
not conflict with my position. Make your diagno- 
ses deliberately and cautiously ; but do not bring 
your patient to the table until it is made, and 
when you do, let it be for the operation, and that 
alone. 

Case X. The following case is reported in the 
London Medical Gazette : 

" Two or three times he was carried to the 
theatre, [of the Hospital] for the purpose of hav- 
ing the operation performed ; but when sounded 
on the table, the stone could not be felt. The 
operation of sounding always excited very excru- 
ciating pain ; the bladder was felt to be roughened 
and hard. After a variety of opinions upon the 
subject, all the surgeons at length agreed that there 
was a stone, and that it was soft." The stone 
broke into pieces. " There was great difficulty in 
extracting them, on account of the extreme softness 
of the external layer of earthy deposit which broke 



72 



under the slightest touch of the forceps. The 
scoop was used to extract the fragments. A large 
dose of opium was given to him immediately after 
he was removed to bed. About an hour after this, 
he was visited, and found to be recovering from 
faintness ; he complained of a little pain. Cam- 
phor julep was directed to be given to him fre- 
quently. In the evening he was tolerably easy, so 
as not to require an anodyne. 

The patient died, and Dr. Hodgkin gave this 
account of the dissection : 

" The bladder was of a moderate size and flaccid, 
and the muscular coat very little, if at all thick- 
ened. The raucous membrane was of a dark olive 
colour, with very general thickening, and abrasion 
on the summits of all the turgid and elevated 
points." 

This in fine, is a case of death from inflamed 
bladder and exhaustion; may not this condition 
of the bladder have been owing in part to the re- 
peated soundings ? Would it not be better in cases 
where the stone breaks and the patient is getting 
exhausted, to leave the fragments, and trust to 
their coming away by keeping the wound open, 
or removing them after the inflammation had sub- 
sided ? 



73 

Extraction of the Stone. 

In an operation I performed on Mr. Purdy, the 
father of the Drs. Purdy of this city, two smooth 
calculi as large as a shilling were discharged with 
the gush of urine that followed the stroke of the 
bistoury. But it is rare that the introduction of an 
instrument is not required for the removal of stones 
after the incision is made. The forceps for this 
purpose may be introduced either upon a blunt 
gorget, used as a conductor, according to the re- 
commendation of Bromfield and Martineau ; or upon 
the index finger of the operator when the stone 
can be reached in this way. A forceps about 
twelve inches long will be found of the most con- 
venient size for an adult. The hinge should be 
at two thirds of the length from the extremity of 
the handles. The instrument with open blades, 
introduced by Dr. J. Rhea Barton, appears to me 
to be an improvement. The hinge of Mr. Weiss, 
too complicated for description, but exceedingly 
simple in operation, allows the blades to be nearly 
parallel when the stone is grasped. Mr. Marti- 
neau makes use of the straight forceps, prefering 
an instrument rather large to the small and flat 
one. 

In introducing the forceps, the blades should be 
on a level with each other, and the instrument 



74 



moved about closed until the stone is felt, if it has 
not been previously felt with the finger. The 
stone will usually be found resting on the posterior 
part of the bladder ; open the instrument with the 
blades one above the other, pass it onward, and 
probably the stone will be properly seized. If it 
is not grasped, and is lying behind the ossa pubis, 
open the blades horizontally, and probably the 
stone will fall down between them. The stone is 
sometimes lodges behind the lower lip of the pros- 
tate. It may be seized there with a crooked for- 
ceps, or what is better, raised to the level of the 
incision by inserting the finger into the rectum. 
If the stone is not properly seized, the grasp of 
the forceps should be relaxed, until it can be se- 
cured with its flat sides against the blades, and its 
longest axis in a line with them. In withdrawing 
the forceps, its blades should be perpendicular to 
one another. In my own practice, if the stone is 
large, I prefer the lever ; in withdrawing the stone, 
the line of traction should be in the direction of 
the axis of the lower strait of the pelvis. How 
much force may be safely employed in the extrac- 
tion of a stone ? Force applied to the stone be- 
fore it is out of the bladder, must be more danger- 
ous than that which is applied after the stone has 
been brought partly out. In the former, the blad- 
der and prostate are contused and lacerated, in 



75 



the latter, the injury is done to less important 
parts, muscles and cellular tissue. It is certain, 
that very successful operators are in the practice 
of using at times, a great deal of force, enough to 
draw the patient from the table, if not held there ; 
and reasoning, no less than experience, justifies 
this practice within certain limits. The alterna- 
tive is in a great degree between a wound contu- 
sed even to disorganization, and an extensive deep 
slough from urinary infiltration, — the former is the 
minor evil. A careful surgeon will not be taken 
by surprise, but be prepared with a suitable in- 
strument for crushing a stone too large to be ex- 
tracted with safety. If the opening of the blades 
of the forceps indicate a stone of more than two 
inches in its smallest diameter, he will not be able to 
remove it by a force equal to the lifting of forty 
pounds, which I conceive is the utmost that is 
justifiable. 

Obstacles to the extraction of the Stone. 

Sir Astley Cooper speaks of spasm of the blad- 
der during the operation, as one obstacle to the 
extraction of the stone. Sir Charles Bell writes 
thus : — "In the contraction of the bladder, after 
the incision for the stone is made, there is a cir- 
cumstance particularly deserving of notice, and 

10 



'6 



which could not be hitherto understood, from inat- 
tention to the structure and action of the muscles 
of the ureters. Some have described the cause to 
which I allude, as a sacculated stone ; others have 
called it the hour-glass contraction of the bladder. 
The fact is this, by the pressure of a stone, and 
the frequent desire to make water, the muscular 
fibres of the bladder acquire a very considerable 
strength and prominence. But of the fleshy col- 
umns, the muscular fibres of the ureters become 
remarkably enlarged. Accordingly it happens, 
that where the incision is made and the urine es- 
capes, these muscles contract, and then the surgeon 
feels a sort of orifice within the bladder beyond 
the edges of the incision ; and through this second 
orifice he can touch the stone with the extremity 
of the fore finger. He finds great difficulty in 
seizing the stone when it is in this confined situa- 
tion."* 

In the operation of lithotomy, I have felt these 
muscles passing down to the ureters, and drawing 
the centre of the bladder nearly into a circle, so as 
to enclose the stone. This, I am inclined to be- 
lieve, has sometimes been called a sacculated cal- 
culus; whereas, it is the natural consequence of 

* Surgical Illustrations, p. 1 14. 



77 



the excitement of the bladder during a protracted 
operation. I have twice met with occurrences 
precisely such as Sir C. Bell here describes. The 
spasm, or temporary sacculated condition, lasted 
but a few moments, and returned several times. I 
prefer the use of the fore-finger of the left hand 
and a lever in such cases to the forceps. 

Sir Charles Bell considers the fibres of the lev- 
ator ani as offering some resistance, but when we 
reflect that it must be shortened by the elevation 
of the anus, it would seem impossible for this 
muscle to offer much resistance ; perhaps the 
aponeuroses which envelope it may present an 
obstacle of more or less force. 

Among the causes, then, opposing the withdrawal 
of the stone, the muscular fibres at the neck of the 
bladder, especially when in a state of spasm, are 
first to be considered. This cause may be over- 
come, without laceration, by steady gentle traction. 

The second cause of resistance is the fibrous 
capsule of the prostate gland. This capsule will 
yield to a limited extent only ; beyond which, if 
force be applied, it will be torn. M. Senn consid- 
ers this the sole obstacle, and from what I have 



78 



seen, both in the living and on the dead subject, I 
am persuaded it offers a strong barrier. 

The third is the substance of the prostate gland 
itself. This is more disposed to be lacerated than 
to be stretched. M. Senn* thinks that the opening 
is enlarged by its compressibility, an effect which 
the solidity of this substance must often prevent. 

* " It is wrong to search in the resistance of the soft parts forming the 
perinaeum, and in that of the lower strait, for the causes of the difficulties 
experienced in extracting calculi of a certain volume. It is at the neck of the 
bladder itself, surrounded and fastened by the prostate, that we really find 
these ; and to be convinced of what I state, it is only necessary to operate 
upon the dead subject ; it will be at once seen that the difficulties are not at 
all changed whether the prostate be covered by the soft parts or not, and that 
upon a well formed pelvis, the interspace between the rami of the arch is 
more than sufficient for allowing the free exit of calculi, the extraction of 
which can be effected by the sub-pubic operation. Besides, it will be 
found, let the urethra be divided as it may, that what we obtain in attempting 
to dilate the wound with the finger, or with instruments, is owing to the com- 
pressibility of the glandular parenchyma which permits itself to be pressed 
together on all sides, or to its rupture ; but not to its extensibility, rendered void 
by the fibro-cellular tunic which envelopes it, and which resists even strongly 
the most considerable pulling. But if, on the one hand, the prostate thus 
supported is opposed to the extraction of foreign bodies, surpassing a certain 
volume, it protects, on the other hand, the body of the bladder, and prevents 
imprudent operators, when attempting to withdraw calculi of too great a vol- 
ume, from producing serious injuries, capable of endangering the life of the 
patients. It is a useful barrier which should not be entirely freed by cutting 
the gland through its whole thickness ; for, by this process, we would be lia- 
ble not only to wound parts which cannot be injured without inconvenience, 
but moreover to produce rupture of the body of the bladder at the moment of 
extraction." 

Recherches sur les differentes methodes de taille sous pubienne par F. L. 
Senn de Geneve. — p. 8 & 9. 



79 



The fourth obstacle is presented by the trans- 
versalis muscle, if its fibres have not been com- 
pletely divided. 

Do the bones of the pelvis ever offer any resist- 
ance ? In the bilateral operation, probably not ; but 
in the lateralized operation, if the incision is not 
carried as near the rectum, and continued as low 
down as it may be with safety, some resistance 
must be caused by them. This resistance would 
be greater were not the prostate and neck of the 
bladder displaced and borne backwards and to one 
side by the yielding of the ligaments of the bladder. 
When great force is applied, these ligaments, as 
well as the cellular tissue behind the pubes, are 
lacerated. The resistance of the bones may, in 
some measure, be eluded by depressing the blades 
of the forceps and drawing in the direction of the 
lower strait of the pelvis. 

In a few words : I consider the resistance to 
arise from the capsule of the prostate, and the 
neck of the bladder ; from the transversalis mus- 
cles when not divided on either side ; from the lev- 
ator ani and its investing fasciae. 

The following experiment was made upon a 
male subject, about 35 years of age, four days 
after his death, the weather being cold : 



80 



A grooved staff was introduced into the bladder 
and a transverse incision, one inch and a half long, 
and one inch anterior to the anus, was made upon 
the staff into the membraneous part of the urethra, 
and the prostatic bisector was introduced along the 
groove into the bladder. The bisector and staff, 
placed in position, measured three inches and a 
half in circumference. The fundus of the bladder 
being then opened, it was ascertained that the in- 
cision had approached within one or two lines of 
the sides of the prostate which, however, were not 
entirely divided. 

A large forceps was then introduced, and an 
egg-shaped stone properly placed within its grasp. 
The stone and forceps, measured together, gave a 
circumference of nearly six inches. The instru- 
ment, with its blades perpendicular, was then pulled 
upon with a force that might have been sufficient 
to lift a weight of twenty pounds, and moved from 
side to side and up and down. The largest cir- 
cumference of the stone did not pass out of the 
bladder until the traction was increased to forty 
pounds. A very moderate degree of force then 
sufficed for its removal ; but there was a sense of 
tearing, as the stone passed through the external 
incisions. It seemed that the fibrous capsule of 
the prostate had offered the first and greatest re- 
sistance ; the levator ani the last. 



81 



The tract of the wound was next exposed to 
view, by extending the left side of the incision 
through the bones and soft parts, so as fairly to 
lift them over to the right side of the pubes. 

In the posterior plane was the lower half of the 
prostate apparently not much contused or lacera- 
ted, (the lower blade of the forceps had covered 
this ;) between it and the anus were the longitudi- 
nal fibres of the rectum about a line in thick- 
ness. On the right side of the prostate were some 
stretched and lacerated fibrous shreds, like fine 
cotton thread, connecting the upper and lower 
halves of the prostate at their edges. Between this 
part and the right extremity of the external incis- 
ion, were indistinct portions of muscular fibres, 
parts of the levator ani and of the transversalis. 
On the left side of the prostate, where the incision 
had been extended after the removal of the stone, 
a large plexus of vessels, filled with venous blood, 
was brought into view. The parts were then 
carefully smoothed with the handle of the scalpel, 
and with this and the finger the loose cellular tis- 
sue was separated until three pouches or cavities, 
more or less connected with the tract of the wound, 
were brought into view ; — the first, high up on 
the right side, was bounded externally by the ob- 
turator internus muscle, internally by the bladder 



82 



and prostate, and inferiorly by the levator ani; 
below the levator ani was another pouch which ex- 
tended in front of the sacrum and behind the rec- 
tum ; between the rectum and the bladder was a 
third cellular space in which the cellular structure 
was rather less loose than in the other two. 

Of Leaving the Stone behind. 

The records of surgery furnish a few cases in 
which, from the exhausted state of the patient, or 
the magnitude of the stone, it had not been ex- 
tracted at the time of the operation, but remained 
a day or a week afterwards, or has been expelled 
by the efforts of the patient. But to send a patient 
from the table with the stone not removed, is 
to leave him to his fate, which must be pretty 
uniformly fatal; and this result, I apprehend, is 
equally to be expected when the slipping of the 
gorget leaves the bladder unopened. The rule for 
getting your instruments into the bladder is hardly 
more imperative than that of getting the stone out.* 

* If any exception is made to this rule, it is in the case of a small stone. If 
this cannot be found after a reasonable search, rather than exhaust the patient, 
it would be better to put the patient to bed, and trust to its expulsion, or to 
search for it after one week has elapsed. 

In the London Medical Gazette, Mr. Travers states that he had operated 
twice without finding the stone ; yet it was the opinion of four or five surgeons 



83 



In the cases of very large stones, the resources 
are, 1st., the high operation ; 2d. the crushing of 
the stone. The former of these has been so gen- 
erally fatal that I would rely upon the latter. 

Of Infiltration of Urine. 

The symptoms of infiltration of urine after the 
operation of lithotomy, are like those which occur 
after the bursting of the urethra behind a stricture ; 
or after the urethra has been lacerated by an in- 
strument or by a fall upon the perinseum. During 
the first few hours there is often nothing remarka- 
ble, except that the patient will acknowledge a 
sense of distension and soreness. You first notice 
a little heat of skin, increased frequency of pulse 
and indisposition to sleep, but not always pain. 
Before the close of forty-eight hours, the pulse 
will rise to 100 or 140 iii a minute ; the counte- 
nance become anxious, the face flushed, and skin 
dry. Soon after this, the pulse will intermit two 
or three times in a minute. Then follows hiccup, 
with abdominal tenderness and distension, and death 
soon afterwards ensues. The condition of the 



that the stones were in the bladder. Both these patients recovered. I have 
known the operation performed in one case where there was no stone : in 
another case, the gorget not entering the bladder, the stone was left. Both 
the cases proved fatal. 

11 



84 



patient previous to the operation, the manner in 
which this has been performed and borne, and the 
period of time afterwards at which these symptoms 
occur, will enable you to distinguish urinary infiltra- 
tion from the exhaustion or sinking caused by the 
shock of the operation upon the nervous system. 

Now the symptoms of urinary infiltration are 
the symptoms of mortification, their cause is mor- 
tification, and their treatment should be the same 
as for this. The means of preventing their occur- 
rence is by affording a ready exit for the urine 
through the external wound. After the patient 
has been placed in bed, pass a wax bougie or a 
hollow gum elastic catheter into the wound, and 
allow it to remain until the flow of urine is perceived 
by the side of the instrument, or through it. I 
prefer a small catheter, as this conducts the urine 
away beyond the buttocks of the patient. It should 
not be passed in further than is absolutely required 
to draw off the urine. If any straining to make 
water is observed, as may happen when the instru- 
ment has partially slipped out, we should have it 
immediately pushed up and properly secured. 

The gravitation of urine will not cause infiltra- 
tion. Where the case goes on well for thirty-six 
hours there is little to be apprehended from infil- 



85 



tration of urine. The effusion of fibrin, by which 
infiltration is prevented, takes place more rapidly 
in childhood than in adult and old age. In con- 
stitutions disposed to diffuse inflammation, the 
effusion of lymph may be delayed indefinitely. 

When infiltration has occurred, the patient 
should have such food as he may desire, and he 
should be supported with wine, ammonia and opium. 
Purging and any antiphlogistic treatment will only 
hasten the fatal termination. In men, the result 
is generally fatal ; in children, it is not always so. 
In the latter, healthy suppuration may come on, the 
sloughs separate, and the patient get well. 

I knew of no one except Sir B. Brodie who has 
ventured upon any local treatment that can be 
considered effective. He passed a blunt bistoury 
to the bottom of the wound, and upon the finger, 
introduced within the rectum divided all the parts 
between the two. This proceeding, worthy of all 
praise, rescued his patient from impending death. 
As external applications, warm and spirituous fo- 
mentations are best suited to such cases until sup- 
puration is fairly established. 

After suppuration, (which indicates a state of 
the system free from the oppressive influence of a 



86 



mortifying tissue,) has been fully established, em- 
ollient applications should be substituted and the 
diet and internal remedies should be of a less 
stimulating character, yet sufficiently tonic to sup- 
port the strength of the patient. 

Or Hemorrhage. 

It is difficult to state with precision what amount 
of blood may be lost in the operation or after it, 
in order to constitute an alarming hemorrhage — 
enough to make the patient swoon upon the table 
or to make him feel faintish at any time after he is 
in bed, is undoubtedly of that character. I should 
feel uneasy for a patient who lost a pound of blood 
during the operation. It is very desirable to avoid 
the use of a ligature or compression. But where 
the force of the arterial jet is great, every prudent 
surgeon will endeavour to apply a ligature at once. 
It is much easier to seize the open mouth of a 
recently cut vessel, or to tie its trunk immediately 
before the vessel has retracted and the parts are sore 
and swollen. If the open mouth of a vessel cannot 
be brought into view, and you find that pressure 
upon the trunk of the internal pudic arrests the 
bleeding, this should be secured by a ligature. 
The operation has been often done and no con- 
siderable difficulty ought, I should judge, to attend 



87 



the performance of it. A probe being passed 
between the artery and the bone and its point 
made to penetrate into the wound, a ligature may 
easily be passed over it, so as to embrace all the 
parts between the wound and the instrument. 

If the blood comes from the upper part of the 
wound, and pressure on the internal pudic does 
not arrest it, the first resource should be cold 
drinks, and the application of cold cloths. Perhaps 
the internal use of sulphuric acid, the acetate of 
lead or the sulphate of alumine might in such 
case be useful. 

In either case, if these means fail it only re- 
mains to employ compression in the following 
manner ; — tie a soft linen cloth around a female 
catheter, about one inch from its beak. Pass this 
into the wound until the beak corresponds with 
the commencement of the urethra. Then fill with 
lint the space between the instrument and the 
cloth, and secure the w r hole with a T bandage. 

Dupuytren invented an instrument which will 
probably be found to answer still better. Its 
shape is like a dissecting forceps with round ex- 
tremities to the outer sides of whose blades are 
attached some firm padding. The elasticity of the 



88 

instrument tends to keep its blades open and thus 
press laterally in opposite directions its padded 
extremities. 

All these haemostatic measures are uncertain, 
painful and very liable to induce dangerous inflam- 
mation. 



Or Inflammation of the Bladder. 

Inflammation of the bladder is attended with in- 
cessant pain at the end of the penis, soreness and 
swelling in the groins, nausea, yellow furred 
tongue, and other symptoms of febrile irritation. 
It is very much beyond the reach of general 
depletion. Leeches, fomentations and the hip 
bath, are the best palliatives. Internal remedies 
tending to irritate the urinary organs, or to act 
violently upon the intestinal canal are hurtful. 
Indeed I have known severe pains at the end of 
the penis, and a great deal of febrile irritation to 
be produced after the operation of lithotomy by 
calomel, followed by infusion of senna. Part of 
this distress, no doubt, was spasmodic — but con- 
tinued spasm of the neck of the bladder may readily 
induce inflammation. An opiate injection is the 
proper remedy. 



89 



Or the Operation in Children. 

An accurate description of the anatomy of the 
parts concerned in lithotomy during the period of 
childhood and adolescence, is a desideratum in sur- 
gical anatomy. My own researches are so limited 
as to render them hardly worthy of being offered 
to the public. It may be stated, however, that the 
prostate is scarcely at all developed before the age 
of puberty. In three subjects examined with special 
reference to this point, it was found that in a child 
of two years old, when the bladder was distended 
with air, the prostate measured laterally ii of an 
inch, and vertically!- of an inch in diameter — its 
parietes being very little if at all more dense than 
the walls of the bladder itself. In a child three 
years and a half old, its lateral diameter was jf and 
its vertical diameter j j. of an inch. In a boy eleven 
years old, its transverse or lateral measurement was 
j£ and its vertical measurement 13 of an inch, its 
parietes being still scarcely any thicker than those 
of the bladder. 

The results of the operation in childhood are 
more favourable than in mature or advanced age. 
This is owing probably to the less depth of the 
perinseum, and perhaps also to the fact that the 



90 



prostate not being developed, the sympathies of the 
genital organs are not excited by the operation. 

Of Lithotomy in the Female. 

I have on six occasions, removed stones or other 
foreign bodies, from the female bladder. 

In a female, on Long-Island, under the care of 
Dr. Purdy, of Great Neck, I found a calculus 
nearly as large as a hen's egg, engaged in the 
urethra, and apparently prevented from coming 
away only by the muscular fibres of the sphincter. 
I cut upon it through the vagina, and hooked it 
out with my finger, leaving the sphincter untouch- 
ed. This occurred about fifteen years since. The 
woman is still living, and I learned from her a few 
months ago, that the power of retaining her water 
is perfect, and that it has been so since a month 
after the operation. 

A black woman was brought to the hospital, in 
the year 1826, with stone in the bladder. I ex- 
tracted without cutting, a foreign substance which 
proved to be a piece of greased brick about as 
large as the thumb. Dr. Ferriar brought to me 
about two quarts of the same materials, which he 
had removed ; each piece being very similar in 



91 



shape and size to the one I removed. I have 
understood that as many more have since been 
taken from the bladder of the same patient. She 
had caries of the spine, brought on, as I suppose, 
by her vile habits. 

An hysterical young woman having retention of 
urine, a gum-elastic catheter was used to draw off 
the water. Soon afterwards it was discovered, 
that the instrument, about eleven inches long, was 
in her bladder. After six weeks, being consulted 
by Dr. Rapalje of Brooklyn, I removed it, by 
dividing the meatus. Two years afterwards, the 
same occurrence took place again in the same 
female. On this occasion I dilated the urethra 
with my finger, so as to pass in a polypus forceps, 
and readily brought away the instrument. At this 
period she had, with her other symptoms, a con- 
stant muco-purulent discharge from the bladder; 
and the catheter, which had remained there ten 
days, was incrusted as in the former case with a 
thick calcareous deposit. 

Although the first of these operations was not 
followed by inability to retain the water, yet I 
prefer the latter method, and conclude that almost 
all calculi may be removed from the female blad- 
der, either whole or broken, by dilatation alone. 

12 



92 



EXPLANATION OF THE PLATES. 

Plate I.— Fig. 1. The Prostatic Bisector. 
Fig. 2. The same seen laterally. 
Fig. 3. A transverse section of the same at its largest part. 

Plate II. — Intended to illustrate the description of the parts of perinaeum, 
as givenat page 26, within which the lithotomist should confine 
his incisions. A, the anus. B, the lower edge of the symphi« 
sis pubis. C, the termination of the os coccygis. DD, the 
tuberosities of the ischia. E, the form and extent of the pri- 
mary incision in the bilateral operation. 

Plate III.— A representation of the deep portion of the perinaeum. The 
superficial parts including integuments, muscles, fasciae, and 
the urethra as far as the [commencement of its membraneous 
portion, have been removed, so as to show the relative position 
of the prostatic portion of the urethra to the walls of the pros- 
tate, and of that body to the rectum, &c. 

AB, The bones forming the lower strait of the pelvis. 

C, The rectum, capable of being distended so as to 
spread out upon the posterior edge of the prostate, 
and partially embrace it, as represented by the dotted 
lines DD. 

E, The prostate gland of natural size in the adult sub- 
ject. 

F, The part of it through which the urethra passes. 

GG, The greatest lateral measurements from the urethra 
to the external borders of the gland. The prostate 
being^stretched by the staflfj these lines represent the 
direction of the incisions made by the bisector. 

HH, The prostatic ligaments passing backwards from the 
posterior part of the pubes. 



93 



Plate IV. — This figure, referred to at page 41 , illustrates the Celsian mode 
of operating for the stone. The index and middle finger of the 
operator are introduced into the anus, so as to reach beyond 
the calculus, and press it outwards through the lunated incision, 
which is continued onward from the integuments in front of the 
anus, until it reaches the stone at the neck of the bladder. 

Plate V. — This figure represents the mode of introducing the prostatic 
bisector, directed by the grooved staff from the bottom of the 
external wound through the prostate gland, into the bladder. 



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